306006344-11-21-2025-22-AS-AORZ-DNN3QY-20251121172756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006344
Report Date: 11/21/2025
Date Signed: 11/21/2025 02:52:38 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/14/2025 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20251114134103

FACILITY NAME:	COGIR OF BREA		FACILITY NUMBER:	306006344
ADMINISTRATOR:	FAYE, SAMUEL		FACILITY TYPE:	740
ADDRESS:	700 MADISON WAY		TELEPHONE:	(714) 681-0105
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 83	DATE:	11/21/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Cynthia Figueroa, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee financially abused resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an investigation for a complaint received in the Regional Office. LPA was greeted and granted entry at 8am by the Concierge and met with Executive Director (ED) Cynthia Figueroa.

LPA requested the following for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report dated 4/9/2025, Omnicare Resident Pharmacy Enrollment form, Resident and Care Agreement, Resident Detail Ledger and email communication with Responsible Party (RP).

It is alleged that the Licensee financially abused resident. R1 moved into the facility on April 10, 2025 and had a diagnosis of Atrial Fibrillation, was ambulatory and had Mild Cognitive Impairment. Per Omnicare Resident Pharmacy Enrollment form, the resident was the Financial Responsible Party, which was signed on April 10, 2025. LPA reviewed the Resident Detail Ledger which reports the resident account had a zero balance as of September 18, 2025.
(Continued on LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20251114134103

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COGIR OF BREA	FACILITY NUMBER: 306006344
	VISIT DATE: 11/21/2025

NARRATIVE

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(Continued from LIC 9099)

LPA interviewed three of three alert residents regarding their finances and if there were any issues with the facility and financial abuse. Three of three residents denied the allegation and stated there were no problems with billing at this time. LPA interviewed one witness. The witness also denied the allegation and had no knowledge of financial abuse of the residents.

LPA interviewed Executive Director (ED) regarding Omnicare medications received for R1 while R1 was out of the community from July 19, 2025. R1 transferred to a higher level of care and medications received for that cycle were destroyed, per community protocol. A new cycle of medications was ordered in September, in anticipation of R1's return to the community, but R1 did not return and passed away on September 18, 2025. Per ED, the September medications were also destroyed. ED will work with Omnicare to handle the medication costs incurred while resident was not in the community.

After discussion regarding Long Term Care Insurance, ED reviewed insurance claim filed and found the clerical error for July 12, 2025. ED confirmed the correct date should be July 19, 2025 and that the facility will resubmit the claim to insurance. ED will provide written documentation to the Responsible Party regarding the financial issues reported to the Licensee to ensure all parties are on the same page. ED also provided this documentation to the LPA via email

Based on LPA's record review and interview, the allegation that Licensee financially abused resident is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director (ED), Cynthia Figueroa, and a copy of this report and LIC 811 was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC9099 (FAS) - (06/04)

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